NCLEX Mark Klimex BLUE BOOK (1)

. In Abruptio Placenta, the placenta ____________ from the uterine wall ____________. - Separates; prematurely 2. Abruptio Placenta usually occurs in (prima/multi) gravida over the age of ____________. - Multigravida, 35 (HTN, trauma, cocaine)Mark Klimek Blue Book 1. In Abruptio Placenta, the placenta ____________ from the uterine wall ____________. - Separates; prematurely 2. Abruptio Placenta usually occurs in (prima/multi) gravida over the age of ____________. - Multigravida, 35 (HTN, trauma, cocaine) 3. How is the bleeding of Abruptio Placenta different from that in Placenta Previa? - Usually painful; bleeding is more voluminous in placenta previa 4. If you are the nurse starting the IV on the client with Abruptia Placenta, what gauge needle should you use? - 18 (in preparation to give blood if necessary) 5. How often should you measure the VS, vaginal bleeding, fetal HR during Abruptio Placenta? - Q5-15 minutes for bleeding, - maternal VS and continuous fetal Monitoring Deliver baby at earliest sign of fetal distress 6. How is an infant delivered when Abruptio Placenta is present? - Usually C-section 7. Is there a higher or lower incidence of fetal death with Abruptio Placenta compared to Placenta Previa? - Higher 8. In what trimester does Abruptio Placenta most commonly occur? - Third 9. At what age are accidental poisonings most common? - 2 years old 10. If a child swallows a potentially poisonous substance, what should be done first? - Call for medical help 11. Should vomiting be induced after ingestion of gasoline? - No- not for gas or any other petroleum products 12. When taking a child to the ER after accidental poisoning has occurred what must accompany the child to the ER? - the suspected poison 1 contact: 13. An elderly client is a (high/low) risk for accidental poisoning? What about a school age child? - high - due to poor eyesight - high 14. What types of chemicals cause burns to oral mucosa when ingested? - Lye, caustic cleaners 15. Children at highest risk for seizure activity after ingestion are those who have swallowed _____________ and ______________. - drugs; insecticides 16. Can impaired skin integrity ever be an appropriate nursing diagnosis when poisoning has occurred? - Yes, when Lye or caustic agents have been ingested 17. What is the causative organism of acne? - P. acnes (propionibacterium acnes) 18. What structures are involved in acne vulgaris? - The sebaceous glands 19. Name 3 drugs given for acne? 1. Vitamin A 2. Antibiotics 3. Retinoids 20. Dietary indiscretions and uncleanliness are causes of acne? - False 21. What are the 3 causative factors in acne vulgaris? 1. Hereditary 2. Bacterial 3. Hormonal 22. Uncleanliness is a cause of acne? - False 23. What is the most common retinoid given to people with acne? - Accutane 24. Accutane is an analog of which vitamin? - Vitamin A 2 25. What is the most common side effect of accutane? And what is the most important in health teaching in administration? - Inflammation of the lips; - Causes birth defects 26. What is the antibiotic most commonly given to clients with acne? - Tetracycline 27. How long will it take for the person to see results when acne is being treated? - 4 to 6 weeks 28. Does stress make acne worse? - Yes 29. How often should the client with acne wash his face each day? - Twice a day 30. What instructions do you give to a client taking Tetracycline? - Take it on an empty stomach and avoid the sunlight (photosensitivity) 31. What are comedones? - Blackheads and white heads 32. What virus causes AIDS? - HIV (Human immunodeficiency virus) 33. The AIDS virus invades the helper ____________. - T-lymphocytes (or CD4 cells) 34. AIDS is transmissible through what four routes? 1. Blood 2. Sexual contact 3. Breast feeding 4. Across placenta in utero 35. HIV is present in all body fluids? - No; only through blood, semen and breast milk 36. Name the 5 risk groups for AIDS 1. Homosexual/bisexual men 2. IV drug users 3. Hemophiliacs 4. Heterosexual partners of infected people 5. Newborn children of infected women 3 37. What is the first test for HIV antibodies? - ELISA 38. What test confirms the ELISA? - Western Blot 39. Which test is the best indicator of the PROGRESS of HIV disease? - CD4 count 40. A CD4 count of under __________ is associated with the onset of AIDS-related symptoms. - 500 41. A CD4 count of under _______ is associated with the onset of OPPORTUNISTIC INFECTIONS. - 200 42. Give 6 symptoms of HIV disease. 1. anorexia 2. fatigue 3. weakness 4. diarrhea 5. night sweats 6. fever 43. Which 2 classes of drugs are given in combination for HIV sero-positivity? 1. NRTI's (Nucleoside Reverse Transcriptase Inhibitors) and PI's (Protease Inhibitors) 2. They prevent viral replication. 44. NRTI (nucleoside reverse transcriptase inhibitors) - An antiviral drug used against HIV - Is incorporated into the DNA of the virus and stops the building process; results in incomplete DNA that cannot create a new virus; often used in combination with other drugs 45. PI's (Protease inhibitors) - Most potent of antiviral meds Inhibit cell protein synthesis that interferes with viral replication. - Does not cure but slows progression of AIDS - Prolongs life, used prophylactically and used in AIDS to decrease viral load and opportunistic infections. 46. What do NRTIs and PI's do? - They prevent viral replication. 47. What does the physician hope to achieve with NRTIs and PI's for HIV? - A delayed onset of AIDS for as long as possible (usually can delay onset for 10-15 years) 4 48. What is the most common NRTI used? - AZT (zidovudine) 49. What is the most challenging aspect of combination drug therapy for HIV disease? - The number of pills that must be taken in 24 hours can be overwhelming. The frequency also makes it hard to remember-an alarm wristwatch is used. 50. Clients with AIDS (gain/lose) weight? - Lose weight 51. The typical pneumonia of AIDS is caused by ___________ ____________. - Pneumocystic carinii 52. What type of oral/esophageal infections do AIDS patients get? - Candida 53. What is the #1 cancer that AIDS patients get? - Kaposi's sarcoma 54. Kaposi's sarcoma is a cancer of the ___________. - Skin 55. T/F: AIDS patients get lymphomas? - True 56. What lab findings are present in AIDS? - Decreased RBC's, WBC's and platelets 57. If the AIDS patient HAS leukopenia they will be on _____________ ________________. - Protective (reverse) Isolation 58. Define Leukopenia - Decrease in WBC, indicated viral infection 59. Without leukopenia the AIDS patient will be on ____________ precautions. - Standard precautions or blood and body fluid precautions 60. When the AIDS patient has a low platelet count, what is indicated? - Bleeding precautions; no IM's, no rectal temperatures, other bleeding precautions 61. Does AIDS require a single room? - Yes - if WBC counts are low 5 62. When do you need a gown with AIDS? - If you are going to get contaminated with secretions 63. When do you need a mask with AIDS? - Not usually unless they have an infection caused by an AIRBORNE bug 64. When do you need goggles with AIDS? - Suctioning - Central line start - Arterial procedures 65. If an AIDS patient's blood contaminates a countertop, with what do you clean? - 1:10 solution of bleach and Water 66. Are all articles used by AIDS patients double-bagged? - No; only those contaminated with secretions 67. Can AIDS patients leave the floor? - Yes; unless WBC's are very low 68. Is dietary protein limited in AGN? - Not usually, however if there is severe azotemia then it may be restricted 69. Define azotemia? - Nitrogenous wastes in the blood (increased creatinine, BUN) 70. What is the best indicator of renal function? - The serum creatinine 71. Do people recover from AGN? - Yes, the vast majority of all clients recover completely from it. 72. How can AGN be prevented? - By having all sore throats cultured for strep and treating any strep infections. 73. What is the most important intervention in treating AGN? - Bedrest - they can walk if hematuria, edema and hypertension is gone. 74. What is the most common dietary restriction for AGN? - Moderate Na+ restriction. - Fluid restriction is #2 if edema is severe. 6 75. What are the urinalysis findings on AGN? - Hematuria - Proteinuria +3 to +4 - Specific Gravity Up 76. How long after strep infection does AGN develop? - 2 to 3 weeks after initial infection 77. How do you assess fluid excess in the child with AGN? - Daily weight 78. What organism causes acute glomerulonephritis? - Group A beta hemolytic strep 79. What happens to the kidney in AGN? - It becomes clogged with antigen-antibody complexes which then causes inflammation and loss of function. 80. How often are vital sign measurements taken in AGN? - Q4 hours with blood pressure 81. Will the client have hypo or hypertension with AGN? Why? - Hypertension, because of fluid retention 82. What are the first signs of AGN? - Puffiness of face - Dark urine 83. What are the three adult stages of development called? - Early adulthood - Middle adulthood - Late adulthood 84. What is the age range for early adulthood? - 19 - 35 85. What is the age range for middle adulthood? - 35 - 64 86. What is the age range for late adulthood? - 64 - death 87. What is the developmental task for EARLY adulthood? - Intimacy vs. Isolation 7 88. What is the developmental task for middle adulthood? - Generativity vs. Stagnation 89. Intimacy vs. Isolation - Erikson's stage in which individuals form deeply personal relationships, marry, begin families 90. Generativity vs. Stagnation - Erikson's stage of social development in which middle-aged people begin to devote themselves more to fulfilling one's potential and doing public service 91. What is the developmental task for LATER adulthood? - Ego Integrity vs. Despair 92. Ego Integrity vs. Despair - (Erikson) People in LATE adulthood either achieve a sense of integrity of the self by accepting the lives they have lived or yield to despair that their lives cannot be re-lived 93. "Time is too short to start another life, though I wish I could," is an example of ___________. - Despair 94. "If I had to do it over again, I'd live my life just about the same," is an example of __________ __________. - Ego Integrity; the result of the positive resolution of the final life crisis viewed as the key to harmonious personality development; the individual views their whole life with satisfaction and contentment. 95. What does AKA mean? - Above the knee amputation 96. What does BKA mean? - Below the knee amputation 97. If the patient had an AKA they should lie ____________ several times per day. - Prone (to prevent flexion contracture) 98. The #1 contracture problem in AKA is ____________ of the _____________ - flexion; hip 99. What will prevent hip flexion contracture after AKA? - Lying prone several times a day 100. What is the #1 contracture problem after BKA? - Flexion of the knee 8 101. How do you prevent flexion contracture of the knee after BKA? - Remind the patient to straighten their knee constantly while standing 102. To prevent post-op swelling, the stump should be __________ for 12 to 24 hours. - elevated 103. How long should the stump be elevated to prevent post op swelling? - 12-24 hours 104. How often should a stump be washed? - Daily 105. When a stump is wrapped, the bandage should be tightest _____________ and loosest _____________. - distally (far from the center), proximally (nearest to the point) 106. If after a right BKA, the client c/o pain in his right toe, he is experiencing _____________. - phantom limb sensation (which is normal) 107. When will phantom limb sensation subside? - In a few months 108. Is it acceptable for the patient to push the stump against a wall? - Yes, this is one way to toughen a stump so it will not break down due to the wear of the prosthetic leg; hitting it with pillows is another good method. 109. An aneurysm is an abnormal _______________ of the wall of a(n) artery. - widening (it is also weakening) 110. What artery is widened in a thoracic aneurysm? - the aorta 111. An aneurysm can result from an _____________ and from ____________. - infection, syphilis 112. The most common symptom of abdominal aneurysm is: - A pulsating mass above the umbilicus 113. Which aneurysm is most likely to have no symptoms? - The abdominal is most often "silent" 114. Which vital signs are most important to measure in clients with aneurysm? - The pulse and blood pressure 9 115. An aneurysm will most affect which of the following, the blood pressure or the pulse? - The pulse, many times the aneurysm will rupture and much blood will be lost before the blood pressure starts to change. 116. What activity order is the client with an aneurysm supposed to have? - Bedrest. DO NOT get these people up. 117. If the client with aneurysm is physically unstable, should you encourage turning, coughing and deep breathing? - No, BEDREST until the client is stable! 118. What class of drugs is the client with an aneurysm most likely to be on? - Antihypertensives 119. What is the BIG danger with aneurysms of any type? - Rupture, leads to shock and death 120. If an aneurysm is ruptured how would you know it? - All signs of shock Decreased LOC (restlessness) Tachycardia Hypotension 121. If an aneurysm ruptures what is the #1 priority? - Get them to the operating room ASAP 122. Is there anything that can be done for the client with a ruptured aneurysm before they get to the operating room? - Yes, if available you can get them into ANTISHOCK TROUSERS but not if this causes a delay in getting them to the operating room 123. The post op thoracic aneurysm is most likely to have which type of tube? - Chest tube, because the chest was opened 124. The post op abdominal aneurysm repair client is most likely to have which type of tube? - NG tube for decompression of bowel 125. If you care for a client who is post-op for a repair of a femoral popliteal resection what assessment must you make every hour for the first 24 hours? - check the distal extremity (far from center) color temperature pain pulse also MUST document 126. What causes angina pectoris? - Decreased blood supply to myocardium, resulting in ischemia and pain 127. Describe the pain of angina pectoris - Crushing substernal chest pain that may radiate 10 128. What drug treats angina pectoris? - Nitroglycerine 129. How do you tell if a client has angina or an MI? - The pain of the two is similar, the way to tell the difference is if nitro and rest relieve the pain. - Angina = nitro and rest relieve the pain - MI = nitro and rest DO NOT relieve the pain 130. How many nitroglycerine tablets can you take before you call the doctor? - 3 tablets 131. How many minutes should lapse between the nitro pills you take? - 5 minutes: Take 1 nitro tab every 5 minutes 3 times, if no relief, call MD 132. By what route do you take nitro? - Sublingual 133. What is the action of nitro? - Dilates coronary arteries to increase blood supply (O2 supply) and reduces preload. 134. What are the top 2 side effects of nitro? 1. Hypotension 2. Headache 135. What precaution must the nurse take when administering topical nitro paste? - Wear gloves; otherwise the nurse may get a dose of the med 136. Everyone with angina needs bypass surgery. (T/F) - False 137. Anorexics are usually __________ under the age of _____. - females, 25 138. The diagnosis of anorexia nervosa is made when there is a weight loss of _______% or more of body weight. - 15 (pt weighs less than 85% of normal body weight) - Hospitalize if 30% weight loss 139. A major mental/emotional nursing diagnosis seen in anorexia nervosa is ___________. - Altered body image 140. The pulse rate of anorexics is tachycardic or bradycardic? - Bradycardic 11 141. List the most common gynecologic symptom of anorexia nervosa? - Amenorrhea 142. What is found over the body of the client with anorexia nervosa? - Lanugo (soft downy hair) 143. What is the top priority in the care of the client with anorexia nervosa? - Intake of enough food to keep them alive, have them gain weight 144. The best goal to evaluate the progress of the client with anorexia nervosa? - An adequate WEIGHT GAIN 145. What is the apgar scale? - Quick objective way to evaluate the vital functions of the newborn 146. When is APGAR scoring performed on infants? - At 1 minute and again at 5 minutes after the birth 147. Name the 6 criteria that are recorded on an apgar scale 1. Cardiac status 2. Respiratory effort 3. Muscle tone 4. Neuromuscular 5. Irritability 6. Color 148. The total apgar score can range from: - 0 to 10 149. The maximum score an infant can receive on any one of the criteria is: - 2 150. A 10 on the apgar means the baby is: - in terrific health 151. A 0 on the APGAR is ________ (bad/good). - Bad, the baby is stillborn 152. On heart rate or cardiac status, a 2 means that the HR is above _______ BPM. - 100 153. On the HR criteria an infant scores a "1" if their HR is _________ than 0 and ____________ 100 - greater, less than 12 154. In order to score a 0 on HR the infant must have a rate of _________. - Zero 155. A high score of 2 is given for respiratory effort if the newborn_____________. - Cries vigorously 156. An infant is given a score of 1 if their respirations are _______ or ________. - Slow or irregular 157. An infant is given a score of 0 for respiratory effort if __________. - They do not breathe 158. In order to get a score of 2 on muscle tone the infant must_________________. - Move spontaneously (actively) 159. To get a score of 1 on the APGAR for muscle tone the newborn must place their extremities in _______________. - Flexion 160. A newborn receives a score of 0 on muscle tone when there is__________ - No movement (limp) 161. To score the maximum of 2 points on neuromuscular reflex irritability the infant must ______________. - Cry 162. If the neonate ____________, they will score a 1 on neuromuscular irritability. - Grimaces 163. To receive a 0 on reflex (neuromuscular) irritability the neonate must exhibit _______. - No response 164. To score a maximum score of 2 on color the child must be ____________. - Totally pink 165. If the child's _______ are ______ and the trunk -face abdomen are ________, the child scores 1 on color. - extremities; blue (cyanotic); pink 166. To get a 0 on color, the infant is: - Completely blue, pale 167. Acrocyanosis - Temporary cyanotic condition, usually in newborns resulting in a bluish color around the lips, hands and fingernails, feet and toenails. May last for a few hours and disappear with warming. 13 168. Appendicitis is an _________ of the appendix due to __________. - inflammation, obstruction 169. Appendicitis occurs most in what age group? - 15 to 35 170. What is the most common complication of appendicitis? - Peritonitis 171. Peritonitis - Inflammation of the peritoneum 172. What is the first sign of appendicitis? - RUQ pain 173. What follows the RUQ abdominal pain of appendicitis? - N/V 174. Where does the pain of appendicitis finally end up? - RLQ 175. What is the name of the RLQ abdominal pain where appendicitis pain finally localizes? - McBurney's Point 176. What is present when rebound tenderness is present? - Peritoneal inflammation 177. What is the highest that the temp will be appendicitis? - 102 F 178. What blood count is elevated in appendicitis? - WBC 179. What is the name for an elevated WBC? - Leukocytosis 180. What is the only treatment recommended for appendicitis? - Surgery; appendectomy 181. Before the client with suspected appendicitis sees the physician, what should be avoided? - Pain meds, enemas, laxatives and food! Pt must be NPO 14 182. To lessen the pain, place the client with appendicitis in ___________ position. - Fowlers (a sitting position) (also use post op) 183. Never apply __________ to the area of the appendix. - Heat (it causes rupture) 184. After an appendectomy, you should document in the nurses notes the return of __________. - Bowel sounds (peristalsis) 185. Name the five/six essential nutrients 1. Carbs 2. Fats 3. Proteins 4. Vitamins 5. Minerals 6. Water 186. The major source of energy for the body is - Carbs 187. Carbs provide ____________ Kcalories per 1 gram - 4 188. Sucrose is a sugar found in ____________ and _____________. - fruits, veggies 189. What is glycogen? - It is a stored formed of glucose/energy manufactured by the liver 190. Lactose is a sugar found in? - Milk 191. When the body does not receive enough carbs it burns ___________ and _____________. - protein, fat 192. The most concentrated source of energy for the body is ___________. - Fats 193. Fats provide ___________ Kcalories per 1 gram. - 9 194. Fats carry vitamins: - A,D,E,K 15 195. The nutrient needed most for growth and repair of tissues is _____________. - Protein (2nd best is Vitamin C) 196. Proteins provide __________ Kcalories per 1 gram. - 4 197. Vitamins and minerals provide energy for the body. (T/F) - False; they are necessary for a body's chemical reactions. 198. Water is present in ALL body tissues. (T/F) - True (even bone) 199. Water accounts for ________ to ___________% of an adult's total weight? - 50 to 60% 200. Name the four basic food groups 1. Milk & Cheese 2. Meat & Legumes 3. Veggies & Fruits 4. Bread & Cereal 201. Water accounts for __________ to _________% of an infant's total weight. - 70 to 75% 202. An individual is overweight if they are ________% above the ideal weight. - 10 203. An individual is obese if they weigh ________% above the ideal weight. - 20 204. What solution and material are used to cleanse the eyes of an infant? - Plain water - Cotton balls - Washcloths 205. Can you use cotton swabs to clean the eyes, nares or ears of an infant? - No, this is dangerous 206. Can you use the same cotton ball/washcloth edge for both eyes? - No, it would cross contaminate. 207. Should you cover an unhealed umbilical site with the diaper? - No; fold the diaper down. 16 208. What temperature is appropriate for the water used to bathe an infant? - 100 to 105 209. What is the #1 purpose of a tepid sponge bath? - Lower body temperature during fever 210. How should the temperature of the water be tested if no thermometer is available? - Dropping water on the inside surface of your forearm. 211. With which body part do you begin when bathing an infant? - Eyes always 212. When cleansing an infant's eye, cleanse from outer to inner canthus? - No, inner to outer 213. Should you retract the foreskin of a 5 week old male, uncircumcised infant to cleanse the area? - No, not until foreskin retracts naturally and without resistance- then it should be retracted, cleansed and replaced. 214. When sponge-bathing with tepid water the correct temp is _____________. - 98.6 F 215. How long does it take for the umbilical stump to fall off? - 7 to 14 days 216. The primary reason why an infant is draped during the bath is to provide privacy. (T/F) - False, the primary purpose of draping is to prevent chilling. 217. You may use friction to remove vernix caseosa from an infant's skin. (T/F) - False, it causes damage/bruising. 218. What solution is commonly used for care of umbilical cord? - 70% alcohol to promote drying (trend is toward soap and water) 219. What cranial nerve is affected in Bell's Palsy? - #7, facial nerve 220. What is the #1 symptom of Bell's Palsy? - One sided (unilateral) facial paralysis 221. Complete recovery from the paralysis of Bell's Palsy should occur in _______ to ______ months. - 4 to 6 17 222. In addition to the facial paralysis, the sense of ______ is also affected in Bell's Palsy. - taste 223. Will the patient with Bell's Palsy be able to close their eye on the affected side? - No 224. Give three eye interventions for the client with Bell's Palsy. 1. Dark glasses 2. Artificial tears 3. Cover eye at night 225. As the prostate enlarges it compresses the ___________ and causes urinary ________. - Urethra, retention 226. At what age does BPH occur? - Men over 50 years of age. 227. What does BPH stand for? - Benign Prostatic Hypertrophy 228. In BPH, the man has (increased/decreased) frequency of urination. - Increased 229. In BPH the force of the urinary stream is (increased/decreased). - decreased 230. The man with BPH has a _________- stream of urine. - forked 231. The man with BPH has hesitancy. What does this mean? - Difficulty starting to void. 232. Will the man with BPH have enuresis, nocturia or hematuria? - Nocturia and maybe hematuria, NOT enuresis 233. Enuresis - inability to control the flow of urine and involuntary urination 234. What is the best way to screen men for BPH? - Digital rectal exam 18 235. Should fluids be forced or restricted in BPH? - Forced 236. What does TURP stand for? - Transurethral resection of the prostate 237. The most radical prostate surgery is the ____________ prostatectomy. - Perineal 238. What type of diet is used in BPH? - Acid Ash 239. Acid Ash diet - Decrease pH (makes urine acid) chz, eggs, meat, fish, oysters, poultry bread, cereal, whole grains, pastries cranberries, prunes, plums, tomatoes, peas, corn, legumes. 240. What is the primary purpose of a 3 way continuous bladder irrigation (CBI) after TURP? - To keep the catheter clear of clots and to drain urine 241. What solution is used for continuous bladder irrigation? - Normal saline (0.9 NaCl) 242. How fast do you run the CBI? - At whatever rate it takes to keep the urine flowing and free of clots 243. What drug is used to treat bladder spasm? - B&O suppositories 244. Should you take a rectal temp after prostatectomy? Give stool softeners? - No rectal temperatures - Yes stool softeners 245. You should call the MD after TURP when you see _________ thick ________, _____________ clots, and ____________ urine drainage on the dressing. - bright, blood, persistent, persistent (don't call MD for transitory clots and urine on dressing.) 246. If you see an increase in blood content of urine coming out of the catheter, you would first ___________. - Pull carefully on the catheter to apply local pressure on the prostate with the Foley balloon. 247. If you see clots in the tubing you would first ____________. - increase the flow-rate. 19 248. What exercises should the post prostatectomy patient do upon discharge? Why? - Perineal exercises, start and stop stream of urine, because dribbling is a common but temporary problem post op 249. Will the post prostatectomy patient be impotent? - If TURP, no impotence; if perineal prostatectomy,yes impotence 250. How often should the drainage bag be emptied? - Every 8 hours 251. What is the most common problem due to catheterization? - UTI 252. What is the most common organism to cause UTI with catheterization? - E. coli 253. What is the most common route for organisms to enter the bladder when a catheterization is used? - Up through the inside of the catheter in the days following catheterization. 254. Name foods that make acid urine: - Cranberry juice - Apple juice (avoid citrus juices- they make alkaline urine) 255. What is important about the level of the urinary drainage bag? - Never have the bag at a higher level than the bladder. 256. How is the catheter taped in a male client? - To the lateral thigh or abdomen 257. How is the catheter taped in a female client? - To the upper thigh 258. What urinary pH prevents UTI? - Acidity, low pH 259. Should the drainage bag ever touch the floor? - No 260. Is it ok to routinely irrigate indwelling catheters? - No 261. What agents are best for catheter care? - Soap and water 20 262. What is the most effective way to decrease UTI with catheters? - Keep the drainage system closed, do not disconnect junction of tubing 263. Give some signs of infection in a foley catheter. - Cloudy urine - Foul smelling urine - Hematuria 264. Is urinary incontinence an indication for catheterization? - No 265. Give three appropriate indications for bladder catheterization? 1. Urinary retention 2. To check for residual 3. To monitor hourly output 266. What are the top 2 diagnoses for a client with a catheter? Which is #1? 1. #1- Potential for infection; 2. Potential impairment of urethral tissue integrity 267. What is systole? - The MAXIMAL force of blood on artery walls. 268. What is diastole? - The LOWEST force of blood on artery walls 269. Accurate blood pressure is obtained by using a cuff that has a width of __________ of the arm. - Two-thirds 270. Which artery is most commonly used to measure blood pressure? - Brachial 271. Can the thigh EVER be used to obtain a blood pressure? - Yes, but this is rare. 272. When pressure is auscultated the first sound heard is the ____________ measurement. - Systolic 273. The change in the character of the sounds is known as the ________. - first diastolic sound 274. The cessation of sounds is known as the _________. - second diastolic sound 21 275. When 2 values are given in a blood pressure the first is the __________measurement. - Systolic 276. When 2 values are given in a blood pressure, the bottom number stands for the change in sounds or cessation of sounds? - Cessation of sounds 277. What is the normal adult blood pressure? - 119/79 278. Abnormally high blood pressure is called____________. - Hypertension 279. What is the pulse pressure? - The difference between the systolic and the diastolic blood pressure. 280. If you deflate a cuff TOO SLOWLY, the reading will be too high or low? Why? - High, venous congestion makes the arterial pressure higher (increases resistance) 281. If you use too narrow of a cuff, will the reading be too high or low? - High 282. Vasoconstriction will ___________ blood pressure. - Increase 283. Vasodilation will ____________ blood pressure. - Decrease 284. Shock will ___________ blood pressure. - Decrease 285. Increased intracranial pressure will _________ the pulse pressure. - Increase or Widen 286. If a blood pressure reading is 190/110, what is the pulse pressure? - 80 mmHg 287. What blood test must be done before a transfusion? - Type and crossmatch 288. What does a type and crossmatch indicate? - Whether the client's blood and donor blood is compatible. 22 289. What should the nurse measure before starting a transfusion? - Vital signs 290. With what solution should blood be transfused? - 0.9 normal saline 291. How many nurses are required to check the blood? - 2 nurses 292. What happens when blood is administered with Dextrose IVs? - The cells clump together and don't flow well 293. If a transfusion reaction occurs, what should the nurse do first? - Stop the blood flow and start running the saline 294. How long can a unit of blood be on the unit before it must be started? - Less than 1/2 hour 295. What should the nurse do with the IV line if a transfusion reaction is suspected? - Keep it open with saline 296. If a transfusion reaction is suspected, what two samples are collected and sent to the lab? - Urine and blood 297. If a unit of blood is infused through a central line it must be__________. - Warmed 298. Which of the following are signs of transfusion reaction? - Bradycardia - Fever - Hives - Wheezing - Increased Blood Pressure - Low Back Pain - Low back pain - Wheezing - Fever - Hives ` 299. What are three types of transfusion reactions that can occur? 1. Hemolytic 2. Febrile 3. Allergic 23 300. What would you do first if you suspected a transfusion reaction? - Stop the blood and start the saline 301. What are the signs and symptoms of a hemolytic transfusion reaction? - shivering - headache - low back pain - increased pulse and - respirations - decreasing BP - oliguria - hematuria 302. What are the signs and symptoms of a febrile transfusion reaction? - Low back pain - Shaking HA - Increasing temperature - Confusion - Hemoptysis 303. What are the signs of symptoms of an allergic reaction to a transfusion? - Hives - urticaria - Wheezing - Pruritus - Joint - Pain (arthralgia) 304. Give three reasons for a blood transfusion: 1. Restore blood volume secondary to hemorrhage 2. Maintain hemoglobin in anemia 3. Replace specific blood components 305. What does blood-typing mean? - Check for surface antigen on the red blood cell 306. When does typing and cross matching need to be done? - Whenever a client is to get a blood product. It is only good for 24 hours. 307. What does blood cross matching mean? - Mixing a little of the client's blood with the donor blood and looking for agglutination. 308. When are hemolytic transfusion reactions likely to occur? - In the first 10 to 15 minutes 24 309. When is a febrile reaction likely to occur? - Within 30 minutes of beginning the transfusion 310. What test identifies Rh factor? - Coombs test detects antibodies to Rh 311. What is the difference between whole blood and packed cells? - Packed cells don't have nearly as much plasma or volume as whole blood does 312. What would you do if the client had an increasing temperature and was to get blood? - Call the MD because blood is often held with an elevated temperature 313. How long should it take for one unit of blood to infuse? - From one hour to three hours 314. How long should you stay with the patient after beginning a transfusion? - At least 15 to 30 minutes 315. What blood type is the universal recipient? - AB 316. What blood type is the universal donor? - O 317. What is the routine for vital sign measurement with a transfusion? - Once before administration - Q15 x 2 after administration is begun - Q1 x1 after transfusion has stopped 318. What IV solution is hung with a blood transfusion? - 0.9 normal saline (No glucose) 319. What gauge needle is used with a blood transfusion? - Large gauge, 18 gauge 320. What other things are appropriate after a blood transfusion reaction? - Call MD - Get a blood sample - Get urine sample - Monitor vitals - Send blood to lab 25 321. Can blood be given immediately after removal from refrigeration? - No, it has to be warmed first for only about 20 to 30 minutes. 322. With what solution and when should a breastfeeding mother cleanse the areola? - Plain water, before and after each feeding 323. For a woman who doesn't have retracted nipples, is towel drying or air drying better? - Air drying of the nipples is best 324. The goal is for the infant to breastfeed for __________ minutes per side. - 20 325. How does the mother break the suction of the breastfeeding infant? - She inserts her little finger into the side of the infant's mouth 326. When should the breastfeeding infant be burped? - After feeding from each breast 327. Assuming no mastitis, on which side should breastfeeding begin with? - Begin nursing on the side that the baby finished on the last feeding 328. How long can breast milk be refrigerated? - 24 hours 329. How long can breast milk be frozen? - 6 months 330. In what type of container should breast milk be stored? - Sealed plastic bags 331. Can you microwave frozen breast milk in order to warm/thaw it? - Never 332. Which two nutrients is breast milk lower in? - Fluoride and iron 333. What should you tell a breastfeeding mother about her milk supply when she goes home from the hospital? - Milk should come postpartum day 3. Breastfeed every 2-3 hours to establish good milk supply. 26 334. Can a woman on oral contraceptives breastfeed? - Should not use OCP during the first 6 weeks after birth because the hormones may decrease milk supply. Estrogen is not recommended. Non-hormonal methods are recommended. Remember breastfeeding is an unreliable contraceptive. 335. What is another name for Buerger's disease? - Thromboangiitis obliterans 336. Which extremities are affected by Buerger's Disease? - Lower only 337. What sex does Buerger's Disease affect most? - Males 338. The group with the highest incidence of Buerger's disease is __________. - Smokers 339. Upon walking, the patient with Buerger's experiences _______ _________. - intermittent; claudication 340. What is intermittent claudication? - Pain in calf upon walking 341. A first degree burn is pale or red? - Red 342. A first degree burn has vesicles. (T/F) - False 343. A second-degree burn is pale or red? - Red 344. A second-degree burn is dull or shiny? - Shiny 345. A second-degree burn has vesicles? (T/F) - True 346. A Second degree-burn is wet or dry? - Wet 27 347. A third-degree burn is white or red? - White 348. A third-degree burn is wet or dry? - Dry 349. A third degree burn is hard or soft? - Hard 350. Of first, second and third degree burns, which has less pain? Why? - Third degree burns - Nerve damage has occurred 351. For what purpose do you use the rule of nines? - To estimate the percentage of body surface burned; is NOT used for children. 352. In the rule of nines, the head and neck receive _______: each arm receives_______. - 9%, 9% 353. In the rule of nines, the front trunk gets_____, the posterior trunk gets_____, each leg gets ______ and the genitalia gets________. - 18%; 18%; 18%; 1% 354. What is the only IM given to a burn patient? - Tetanus toxoid; if they had a previous immunization Tetanus antitoxin - If they have never been immunized before (or immune globulin) 355. In the emergent phase, do you cover burns? (in the field) - Yes, with anything clean and dry. 356. Should you remove adhered clothing on a burn patient? - No 357. Name the 3 phases of burn: 1. Shock 2. Diuretic 3. Recovery 358. Fluid moves from the___________ to the _______ in the SHOCK phase. - bloodstream; interstitial space 359. The shock phase lasts for the first ________ to ________ hours after a burn. - 24 to 48 hours 28 360. During the shock phase of burn management, is potassium increased or decreased? Why? - Increased; because of all the cells damaged. The K+ is released from damaged cells. 361. What acid-base disorder is seen in the shock phase of a burn? - Metabolic Acidosis 362. What is the #1 therapy in the shock phase of a burn? - Fluid replacement/resuscitation 363. What is the simple formula for calculating fluid replacement needs in the first 24 hours? - 3cc X Kg X % burned per day 364. If the MD orders 2,800 cc of fluid in the first 24 hours after a burn, one-_____ of it must be infused in the first 8 hours. - Half (or 1,400 cc) 365. What blood value will dictate IV flow rate? - hematocrit 366. How will you know the patient has entered the fluid mobilization or diuretic phase? - The urine output will INCREASE. 367. How long does the fluid mobilization or diuretic phase of a burn last? - 2 to 5 days 368. In the diuretic phase, K+ levels fall or rise? - Fall; remember diuresis always causes hypokalemia 369. If the nurse accidentally runs the IVs at the shock phase rate during the diuretic phase the patient will experience? - Pulmonary edema 370. The burn patient will be on _______urine output and daily __________. - hourly; weight 371. Sulfamylon cream__________. - Burns 372. Silver nitrate cream___________ the ________. - stains, skin 29 373. Pain medications should be administered _______ before ________ care. - 30 minutes, wound care 374. When using silver nitrate, the dressings must be kept __________. - Wet 375. What is Curling's ulcer? Why is it a problem in burn patients? What drug prevents it? - It is a stress GI ulcer (stomach or duodenum) - You get these with any severe physical stress (such as in massively burned patients) - Tagamet, Zantac, Pepcid (any H2 receptor antagonist), Protonix Prilosec 376. Neoplasm refers to benign and malignant tumors. (T/F) - True 377. Which type of tumor is more malignant? Differentiated or undifferentiated? - Undifferentiated is worse to have (highly differentiated is better to have) 378. When cancer spreads to a distant site, it is called: - Metastasis 379. The cause of cancer is known. (T/F) - False 380. A person should have a yearly work up exam for cancer detection over the age of __________. - 40 381. In general, cancer drugs have side effects in which three body systems? 1. GI 2. Hematologic (blood) 3. Integumentary 382. What are the 3 most common chemotherapeutic GI side effects? 1. N/V 2. Diarrhea 3. Stomatitis (oral sores) 383. Clients receiving chemotherapy must be NPO. (T/F) - False 384. Is it permissible to give lidocaine viscous ac (before meals) if the patient has chemotherapeutic stomatitis? (T/F) - True 30 385. With what solution should the client with chemotherapeutic stomatitis rinse pc (after meals)? - H2O2 - hydrogen peroxide 386. What lubricant can safely be applied to the cracked lips of chemotherapy stomatitis? - K-Y Jelly 387. Name the 3 hematologic side effects of chemotherapy. 1. Thrombocytopenia 2. Leukopenia 3. Anemia 388. Which cells are low in thrombocytopenia? - Platelets 389. What drug should NOT be given to the patient with chemotherapeutic thrombocytopenia? - ASA (aspirin) 390. When should the nurse WITHHOLD IM injections in the client on chemotherapy? - Only when their PLATELET count is down. 391. What are the 3 objective symptoms/signs of thrombocytopenia? Hint: P.E.E. - Petechiae - Epistaxis - Ecchymosis 392. What is epistaxis? - Nose bleeds 393. What is ecchymosis? - Bruising 394. What is petechiae? - Small dot-like pinpoint hemorrhages on the skin. 395. What blood cell is low in leukopenia? - White blood cells 396. When the Absolute Neutrophil Count (ANC) is below________, the person on chemotherapy will be placed on reverse isolation. - 500 397. What is the #1 integumentary side effect of chemotherapy? - Alopecia 31 398. What is alopecia? - Hair loss 399. The hair loss due to chemotherapy is usually temporary? (T/F) - True 400. Can scalp tourniquets prevent chemotherapy alopecia? - In some cases, yes 401. Can ice packs to the scalp prevent chemotherapy alopecia? - In some cases, yes 402. CD ranks ________ among the leading cause of maternal death. - Fourth 403. What is the #1 cause of CD pregnancy? - Rheumatic heart disease 404. Pregnancy requires a __________ increase in the cardiac output. - 30-50% 405. What is the #1 cause of maternal death in CD of pregnancy? - Decompensation 406. What is meant by decompensation? - Failure of the heart to maintain adequate circulation. 407. What will you see when you observe the neck of a client with CD pregnancy? - Distended neck veins -JVD 408. What will you hear when you auscultate the heart of the client with CD pregnancy? - Murmurs 409. What will you hear when you auscultate the lungs of the client with CD of pregnancy? - Crackles-rales 410. If the client with CD pregnancy experiences sudden heart failure what is the MOST common thing you will see? - Sudden onset of SOB (dyspnea). 32 411. What is the #1 treatment of CD during pregnancy? - Rest 412. What are the three most common drugs given to women with CD in pregnancy? 1. Diuretics 2. Heparin 3. Digitalis 413. Why are diuretics given to women with CD of pregnancy? - To promote diuresis which will: - lower circulating blood volume - decrease preload - decrease the amount of blood the heart pumps. 414. Why are anticoagulants (heparin only) given to women with CD of pregnancy? - To prevent thrombophlebitis due to venous congestion, usually in legs. 415. Why is digitalis given to women with CD of pregnancy? - To increase the strength of the heart and to decrease the rate, rest the heart while making it more efficient 416. Can a woman with CD pregnancy be given analgesics during labor? - Yes, in fact they should be given analgesics, may get too anxious which is bad for the patient 417. Can morphine be given to a woman with CD during labor? - Yes, even though it negatively affects the fetus, remember morphine decreases preload and pain which rests the heart. 418. What is the most common dietary modification for the woman with CD who shows signs of decompensation? - Decreased sodium, decreased water (restriction) 419. Is a C-section mandatory for delivery of a woman with CD pregnancy? - No 420. Second to rest, what is a very important treatment for CD pregnancy? - Weight control 421. How long must the woman with a CD of pregnancy be on bed rest after delivery? - At least one week 422. What nutrients should be supplied in the diet of the pregnant woman with CD? - Iron - Folic acid - Prevent anemia (anemia always makes the heart work more) 33 423. What are the two most common subjective complaints of the woman who is decompensating during labor? 1. SOB 2. Palpitations 424. In addition to the things you assess for every woman during labor, what additional assessment must you make for a woman with CD? - You must assess lungs sounds frequently 425. How often must you assess the lung sounds during the first stage of labor? During active labor? During transition labor? - Every 10 to 30 minutes 426. In which position should a woman with CD in labor be? - Semi recumbent, HOB up 427. The nurse should limit the client's efforts to ________ ______ during labor when CD is present. - Bear down 428. What is the big danger to staff when caring for a client with a cesium implant? - Radiation hazard 429. What are the three principles to protect yourself from radiation hazard? 1. Distance 2. Shielding 3. Time 430. Will the woman with a cesium implant have a foley? - Yes 431. From where should the nurse provide care to the client with a cesium implant? - The head of the bed 432. How can a woman with a cesium implant move in bed? - Only from side to side 433. What four symptoms in a patient with a cesium implant should be reported to the physician? 1. Profuse vaginal discharge 2. Elevated temp 3. Nausea 4. Vomiting (these indicate infection and perforation) 434. Should pregnant staff care for a client with a cesium implant? - No 34 435. Can the woman with a cesium implant have the HOB elevated? - Yes; only 45 degrees maximum 436. From where should the nurse talk to the client? - The entrance to the room 437. Is bed rest necessary when a woman has a cesium implant in place? - Yes; absolute bed rest 438. What type of diet is this woman with a cesium implant on? - Low residue (decrease bowel motility ) 439. No nurse should attend the client with a cesium implant more than ____ per day. - 1/2 hour 440. What would you do if the cesium implant came out? - Pick it up with forceps only; never touch it with your hands even if you are wearing gloves. 441. Should the nurse provide perineal care for the client with a cesium implant? - No, risk of radiation hazard 442. What part of your hand do you use to handle a wet cast? - The palm 443. Upon what do you support a cast while it dries? - Pillows (no plastic covers) 444. How long does it take a cast to dry? - 24 hours 445. Should you cover a wet cast? - No 446. Should you use a heat lamp or hair dryer or fan to help dry a cast? - No heat lamp and hair dryer - Yes fan 35 447. What signs or symptoms would you report if they were present after cast application? - Numbness - Tingling - Burning - Pallor - Unequal or absent pulses - Unequal coolness 448. If there is inflammation under a cast, it will be evident in a _______ spot. - hot 449. To prevent irritation of the skin near the edges of a cast the edges should be ____________. - Petaled 450. What type of cast causes cast syndrome? - A body cast 451. What causes cast syndrome? - Anxiety and stress leading to sympathoadrenal shut down of the bowel 452. What is the #1 symptom of cast syndrome? - Nausea and vomiting due to bowel obstruction 453. What is the #1 treatment of cast syndrome? - NPO and NG tube for decompression 454. A dry cast is gray or white? - White 455. A dry cast is dull or shiny? - Shiny 456. A dry cast is dull or resonant to percussion? - Resonant 457. Traction is used to _______ and _______ a fracture, relieve ________ _______ and prevent ________. - reduce; immobilize; muscle spasm; deformities 458. Can skin traction be removed for skin care? - Yes 459. Can the client be removed from skeletal traction? - No 36 460. Name 3 types of skin traction 1. Bucks 2. Bryants 3. Pelvic 461. Name 3 types of skeletal traction 1. Cranial tongs 2. Thomas splints with Peason attachments 3. 90 degrees to 90 degrees 462. What type of traction is most commonly used for hip fracture in adults? - Bucks 463. What type of traction is most commonly used for hip fractures in children? - Bryants 464. In what position should the bed be if the patient is in pelvic traction? - Semi-fowlers with knee gatched 465. To ensure that Bryant's traction is working, the child's hip/sacrum should be _________. - off the bed enough to slip a hand between the sacrum and the bed 466. What is the advantage of balanced counteraction? - You can easily move the patient around in bed 467. Patients in Russell's traction are particularly prone to ____________. - Thrombophlebitis 468. When a patient is in a Buck's traction they may turn to the _________ side. - Unaffected 469. Define cataract: - Opacity of the crystalline lens 470. Is surgery done immediately upon diagnosis of cataract? - No, they usually wait until it interferes with ADLs . 471. What three most common visual defects occur with cataract? 1. Cloudiness 2. Diplopia (double vision) 3. Photophobia (sensitivity to light) 37 472. What are the two common treatments of cataract? 1. Laser 2. Surgical removal (surgery called intraocular or extraocular lens extraction) 473. What does the eye look like when a client has cataracts? - Cloudy, milky-white pupil 474. What will the client be wearing after cataract surgery? - A protective patch/shield on the operative eye for 24 hours, then a metal shield (AT NIGHT only) for 3 weeks 475. When the client asks about the use of glasses or contacts after cataract surgery, what would you say? - If an intraocular lens is implanted they will NOT need glasses. If no lens is implanted, then contacts will be fitted for 3 months post-op, temporary thick glasses given immediately but will get a different prescription in 2 to 3 months 476. What will be a high priority nursing diagnosis for a client post cataract surgery? - Safety 477. Should the client ambulate independently after cataract surgery? - No the patient should not ambulate independently, depth perception is altered. 478. What positions are to be avoided after cataract surgery? - Lying face down; also, do not lie on the operative side for a month. 479. What are the postoperative signs of hemorrhage into the eye? - Severe pain - Restlessness 480. What movements are to be avoided after cataract surgery? - Coughing - Sneezing - Bending at the waist - Straining at stool - Rubbing or touching eyes - Rapid head movements 481. What positions are okay after cataract surgery? - Do not lie on operative side; do not lie on back 482. Should you use talcum powder with a post-operative cataract client? - No, it may cause sneezing; also should avoid pepper. 38 483. What are the three signs of increased intraocular pressure? 1. Pain (moderate to severe) 2. Restlessness 3. Increased pulse rate 484. What is the major objective in caring for a client after surgical cataract removal? - To prevent pressure in or on the eyes 485. When the lens is to be extracted for cataracts, what drugs are given preoperatively? - Mydriatics Dilators - Antibiotic drugs (gtts) 486. What three drugs are given post-operatively for surgical cataract removal? 1. Stool softeners 2. Antiemetics 3. Analgesics (mild to moderate) 487. Give five causes of cataracts? 1. Injury 2. Congenital 3. Exposure to heat 4. Heredity 5. Age 488. Celiac's disease is a __________ disease - Malabsorption 489. The client with celiacs cannot tolerate___________. - Gluten 490. Gluten is a __________. - Protein 491. What does gluten do to the intestines of the client with celiac's disease? - It destroys the lining of the intestine. 492. The stools of a client with celiac disease are ______, ______ and _____- _____. - large; greasy; foul-smelling 493. Clients with celiac's disease do not absorb what mineral? - Iron 494. Clients with celiac's disease don't absorb fats; therefore they don't absorb _____ ______ ______. - fat soluble vitamins 39 495. What are the four fat-soluble vitamins? 1. A 2. D 3. E 4. K 496. Malabsorption of which vitamin leads to bleeding disorder? - Vitamin K; remember do not mix up potassium with Vitamin K 497. What will the abdomen of clients with celiac's disease look like? - Distended with flatus 498. What is the #1 treatment of celiac's disease? - Gluten-free diet 499. Veggies are allowed or not allowed in the diet of clients with Celiac's disease? - Allowed 500. Fruits are allowed or not allowed? - Allowed 501. Grains of all kinds are prohibited. (T/F) - False 502. What grains are allowed in a gluten-free diet? - Rice and corn 503. What grains are not allowed in a gluten-free diet? - Wheat - Oats - Rye - Alfalfa - Barley 504. Are foods made with wheat, oat, or rye flour allowed? - No 505. Is milk allowed on a gluten-free diet? - Yes 506. Are meats allowed on a gluten-free diet? - Yes, but watch for breaded meats and hot dogs/lunch meats; may have grains in them which are not allowed 507. Are eggs allowed on a gluten-free diet? 40 - Yes 508. Is commercial ice cream allowed on a gluten-free diet? - No, even though it is a milk product, commercial ice cream has GRAIN in it. 509. Are puddings allowed on a gluten-free diet? - No, for the same reason ice cream isn't. 510. Which soups are not allowed on a gluten free diet? - Creamed soups- these often have flour 511. The #1 problem with central lines ___________ - Infection 512. How often should central line dressings be changed? - QOD- every other day 513. What type of dressing is applied to a central line insertion site? - Sterile occlusive 514. Can drugs be piggybacked into central --TPN? - No, use another lumen. 515. When changing central line tubing the patient should be told to_________? - Turn his head away from the site, hold breath, and perform the Valsalva maneuver 516. If a central line is found accidentally open the patient should be positioned on his ______ ______. - left side 517. A CVA is a __________ of the brain cells due to decreased _____ _____ and ______. - destruction; blood flow; oxygen 518. Women have a (higher/lower) incidence of stroke than men? - Lower 519. Name the three types of CVA 1. Embolus 2. Thrombus 3. Hemorrhage 520. Use of oral contraceptives increases the risk of CVA (T/F). 41 - True 521. Chronic abuse of alcohol increases risk of CVA. (T/F) - False 522. Obesity increases risk of CVA (T/F) - True 523. Smoking increases the risk of CVA. (T/F) - True 524. Atrial fibrillation increases the risk of CVA (T/F) - True; emboli particularly 525. What is a TIA? - Transient Ischemic Attack; warning sign of impending CVA (transient neurologic deficits of any kind can last 30 seconds to 24 hours) 526. Do patients experiencing a CVA have a headache? - Yes 527. The first sign of CVA is usually a___________. - Change in LOC 528. The activity order in early management of CVA is __________. - Absolute Bed Rest 529. The patient with a recent CVA is most likely to have fluids restricted or forced? - Restricted 530. How far should the HOB be up after CVA? - 30 degrees 531. Can the stroke victim be turned side-to-side? - Yes 532. How often should the CVA patient be turned or repositioned? - Every 2 hours 533. The CVA patient should be turned onto his paralyzed side no longer than 2 hours. (T/F) - False, the patient should not be on their paralyzed side for more than 20 minutes. 534. ROM exercises should occur every 2 hours in CVA patients. (T/F) 42 - False; every 4 hours or 3 times a day is enough 535. To prevent urinary incontinence, the CVA patient should be catheterized. (T/F) - False; remember incontinence will never be allowed as a reason for catheterization 536. Which type of paralysis is typical of CVA- paraplegia, hemiplegia or quadriplegia? - Hemiplegia 537. What anatomical fact accounts for the left side of the body being controlled by the right brain? - The motor-pyramidal-tracts cross over to the other side (decussate in the medulla) 538. If the patient has right hemiplegia, he cannot move his ____ ____ and ____ ____ and the stroke was on the _________ side of the brain. - right arm; right leg; left 539. What is hemianopsia? - Not being able to see one half of the field of vision. 540. The client with hemianopsia should be taught to ____________. - Scan 541. What is scanning? - Moving the head from side to side to see the whole field of vision. 542. If the client has right homonymous hemianopsia, the food on the ____ side of the tray may be ignored. - Right 543. After meals, the nurse must always check _______ of the CVA client for _________. - mouth (cheek); food 544. Should a CVA patient have all four side rails up at all times? Should they be restrained? - Side rails yes. Restraints- no, unless they are a danger to themselves or others 545. When a patient does not understand INCOMING language he is said to have ______ aphasia. - Receptive 546. When the CVA client understands your question but can't respond verbally correctly, he is said to have ___________ aphasia. - Expressive 547. What is global aphasia? - Both receptive and expressive 548. Aphasia is most common if the stroke occurred in the (dominant/non-dominant) hemisphere of the brain. 43 - Dominant 549. How do you tell which side of the person's brain is dominant? - It is the side that controls their dominant hand, ie, a left handed person has a dominant right hemisphere and conversely a right hand person has a dominant left hemisphere 550. For which type of aphasia are slow, short, simple directions most useful? - Receptive 551. For which type aphasia is careful listening and needs anticipation most useful? - Expressive 552. The loss of the ability to perform purposeful, skilled acts, i.e. brushing teeth, is called __________. - Apraxia 553. Cytoxan Cyclophosphamide - Hemorrhagic cystitis 554. Cisplatin - Peripheral neuropathy, constipation, ototoxicity 555. Bleomycin - Pulmonary fibrosis 556. Adriamycin - Cardiotoxicity 557. Vincristine - Peripheral neuropathy (foot drop, numbness and tingling, hoarseness, jaw pain) constipation (adynamic ileus due to neurotoxicity) 558. DTIC dome - Flu-like symptoms Chemo-therapeutic Agent Toxicities 559. Methotrexate - Toxic to just about every organ except to heart, toxicity made worse with aspirin 560. The infant fears _________ most when hospitalized. - Separation from love object 561. The toddler fears _______ most when hospitalized. 44 - Separation from family 562. The preschooler fears separation as well as _________ when hospitalized. - Mutilation- remember preschoolers have vivid imaginations...fantasy 563. The toddler and preschooler will think that illness is caused by_____________. - Something they did wrong. 564. The school-aged hospitalized child is afraid of separation from ___________. - Age group 565. The school-aged child perceives the cause of illness to be external or internal? - External; she knows that illness is not a result of bad behavior. 566. The adolescent who is hospitalized fears separation from _________ and loss of ___________. - Peers, independence 567. Preschoolers may require physical restraint during painful procedures. (T/F) - True 568. Which age group engages in stalling tactics before painful procedures most? - School-Age 569. Which age groups are most likely to physically resist the nurse during procedures? - School-age, adolescents 570. Toddlers may require physical restraint for painful procedures. (T/F) - True 571. The meats that are highest in cholesterol are _________ meats. - Organ meats - Liver - Heart - Brains - Kidneys 572. The meats that are second highest in cholesterol are the ___________. - Shell seafood- shrimp, crab, lobster 573. Egg white is (high/low) in cholesterol? - Low 574. Egg yolk is (high/low) in cholesterol? 45 - High 575. The three meats lowest in cholesterol are _________, _________ and __________. - Chicken, pork, mutton 576. Milk is (high/low) in cholesterol. - Low 577. Is cheese high in cholesterol? - Only moderate, not really that high 578. Which oils are high in cholesterol? - Animal oils 579. Is cholesterol a triglyceride? - No 580. Do plant foods contain any cholesterol? - No, not many 581. What is otitis media? - Chronic infectious/inflammatory disease of the middle ear 582. Is otitis a disease of the adult or child? - Usually the child 583. What part of the ear is involved in otitis media? - Middle ear 584. What are the 2 common subjective signs of otitis media? 1. Hearing loss 2. Feeling of fullness in the ear 585. What are the 2 common objective signs of otitis media? 1. Hyperpyrexia (fever) 2. Drainage from ear 586. What commonly happens secondary to otitis media? - Perforation of the eardrum 587. Do all the children with otitis media need tubes in their ears? 46 - No 588. What are the two most common medical treatments for otitis media? 1. Systemic antibiotics 2. Antibiotic ear drops 589. What is the most severe complication of otitis media? - Meningitis or mastoiditis 590. What is cholesteatoma? - An epidermal cyst in the ear highly associated with otitis media. 591. What are the restrictions to be followed when tubes are in a child's ear? - No swimming, no showering, no diving 592. What is cleft lip? - The lip is open to the nares 593. What is cleft palate? - The roof of the mouth is open to the nasopharynx. 594. Is it possible to have only one: cleft lip or cleft palate? - Yes, you can have one or or the other or both 595. When will the cleft lip be repaired? - Between 10 weeks and 6 months 596. When is cleft palate repaired? - Between 1 and 5 years of age 597. Why is the cleft lip repaired early? - Feeding is easier after repair and appearance after repair is more acceptable to parents. 598. Describe the nipples on bottles used to feed babies with cleft lip? - Large-holed, soft nipples 599. The infant with cleft lip/palate needs more frequent ___________. - Bubbling, burping 600. Children with cleft lip/palate should be fed in what position? - An almost upright position 601. What is the #1 complication of cleft lip/palate? 47 - Aspiration 602. Children with cleft lip and cleft palate have long-term problems _____, _____ and _____. - hearing; speech; teeth 603. In how many surgeries is cleft palate repaired? - Two surgeries one at 12 to 18 months the last at 4 to 5 years 604. Why is final repair of the palate delayed until 4 to 5 years? - Earlier surgery would interfere with tooth development. 605. How are cleft lip and cleft palate primarily treated? - Surgical repair 606. Is the infant restrained BEFORE repair? - No, just AFTER repair 607. Should children with cleft palate BEFORE surgery be allowed to cry? To breast-feed? - Yes, they can cry; may breastfeed with simple cleft lip however palate interferes with feeding 608. AFTER repair of the cleft lip is the infant allowed to cry? To breastfeed? - No, the infant should be held to PREVENT CRYING; the infant is not allowed to breast-feed because sucking is not good after lip repair. 609. After cleft lip repair, what device will the baby wear? - A Logan bow 610. What is the purpose of a Logan Bow? - To prevent stress on the suture line 611. With what device will the infant be restrained? - Elbow restraints 612. How do you care for an infant with a Logan Bow? - Remove the gauze before feeding and cleanse after feeding with peroxide and saline. 613. Can cleft lip /palate babies sleep on their backs? - Yes 614. What position is contraindicated after cleft lip repair? - NEVER lie on their abdomen 615. What will be used to feed the infant after cleft lip repair? 48 - A dropper/syringe with rubber tip to discourage sucking 616. What must the mother do after feeding the baby who has had cleft lip/palate repair? - Rinse the infant's/child's mouth with water 617. What is a colostomy? - A surgically created opening of the colon out onto the abdomen wall. 618. Name the 3 most common reasons for a colostomy. 1. Cancer 2. Diverticulitis 3. Ulcerative Colitis 619. What is meant by the term "temporary colostomy"? - A colostomy that is not intended to be permanent the bowel will be reconnected at a later date and the client will defecate normally 620. What is meant by the term "double barrel" colostomy? - A procedure where the colon is cut and both ends are brought out onto the abdomen. 621. Colostomies performed for cancer tend to be (temporary/permanent). - Permanent 622. Colostomies performed for a gunshot are usually (temporary/permanent) - Temporary 623. In a double-barrel colostomy, from which stoma (barrel) will the stool come out? - Proximal 624. A fresh new stoma is _________, __________ and __________. - Red, large, noisy 625. When a client voices embarrassment over the noises that their colostomy makes on the first post-op day, what would you say? - The noise will go away in a few days to a week. 626. What behavior on the part of the client is the BEST indicator that they have accepted their stoma? - When they do their own stoma care 627. By what day post-op should the client begin to take care of their own stoma? - By the 3rd to 4th day, they should be looking at it and asking questions by day 2. 628. The MORE colon is removed the more _________ the stool. 49 - Liquid 629. What technique is used to remove feces and flatus from the bowel through a colostomy? - Colostomy irrigation 630. How many times per day will the client